Accommodative Ability in Pre-presbyopic Diabetic Patients

Mohammad Etezad Razavi1 (MD); Mohammad Sharifi1* (MD); Majid Abrishami1 (MD); Mojtaba Zaker Abbasi1 (MD)
1.
Eye Research Center, Mashhad University of Medical Sciences, Mashhad ,Iran.

ARTICLEINFO ABSTRACT
Article type: Introduction: To compare various accommodative parameters in pre-
Original Article presbyopic diabetic patients with age-matched healthy individuals.
Materials and Methods: Study population consisted of 32 younger-onset
Article history: diabetic patients (30-40 years of age) and 28 age-matched healthy normal
Received: 21-Oct-2014 individuals. Using the best correction for distance visual acuity (20.20 by
Accepted: 10-Nov-2014 Snellen chart), multiple accommodative ability tests such as near point of
accommodation, accommodative amplitude, negative or positive
Keywords: accommodative facility and near point of convergence were measured in both
Accommodation groups.
Convergence Results: Mean near point of accommodation in diabetic patients was
Diabetic significantly greater than the control group (18.5±4.4 centimeters [cm] versus
Pre-presbyopic 9.5±2 centimeters, p= 0.000). Mean accommodative amplitude was (5.93±1.75)
Diopter (D) and (10.95±2.16) Diopter in diabetics and normal individuals,
respectively (p=0.000). Mean accommodation facility was (3.19±3.04)
cycle/minute [cyl/min] in patients and 10.01±5.09 cycle/minute in the control
group (p= 0.000). Mean positive relative accommodation was (–3.37±1.19) D
in diabetic and (-2.11±0.99) D in healthy participants (p=0.000). Mean negative
relative accommodation was lower in diabetic patients compared with the
control group, however, this difference did not reach statistical significance
(2.61±0.65) D versus (2.61±0.60) D, p= 0.23). Mean near point of convergence
was (8.23±1.43) cm and (7.13±0.67) cm in normal and diabetic groups,
respectively which had insignificant difference (p= 0.45).
Conclusion: Majority of accommodative ability functions decreased in Pre-
presbyopic diabetic patients. Early detection and rehabilitation of such patients
with corrective near spectacles are strongly recommended.

Please cite this paper as:

Etezad Razavi M, Sharifi M, Abrishami M, Zaker Abbasi M. Accommodative Ability in Pre-presbyopic Diabetic Patients. Patient
Saf Qual Improv. 2015; 3(2):203-205.

Introduction
Accommodation is the mechanism by which the eye
changes its refractive power by altering the shape of the
crystalline lens (1). During accommodation, ciliary
muscles contract, allowing the zonular fiber to relax
and the crystalline lens become more convex, far point
moves closer to the eye to focus on near objects (1, 2).
If crystalline lens elasticity decreases (due to aging
process or a systemic condition like diabetes mellitus),
accommodative response reduce (2).These patients
require additional spectacle lens power to see near
objects clearly. Few studies were performed on young
diabetic patients to evaluate only accommodation
amplitude and/or convergence.ETDRS group in 1995
compared Amplitude of Accommodation(AA) in white
Pre-presbyopic diabetic and normal subjects. They used
spherical lens power for AA measurement. They found
that AA was lower in diabetic patients and the mean
AA for a 35-year-old diabetic patient was about four
diopters(3).In this study, for first time we performed
multiple accommodative ability tests in Pre-presbyopic
(less than 40 years of age) diabetic patients to compare
their accommodation characteristics with those normal
individuals.
Materials and Methods
This cross-sectional case-control study was
performed on patients who were referred to one of the
teaching hospitals of Mashhad University of Medical
Sciences. Informed consent was obtained in accordance
with the Declaration of Helsinki. There were two
groups of young adult subjects,one group(n=32) with
young – onset diabetes and control group(n=28)

© 2014 mums.ac.ir All rights reserved.

*Corresponding Author: Mohammad Sharifi, Eye Research Center, Mashhad University of Medical Sciences, Mashhad ,
Iran.Email:Sharifim@mums.ac.ir
Etezad Razavi et al
without diabetes.Inclusion criteria for diabetic group
were individuals ages ranged between 30 and 40 years,
detected diabetes by endocrinologist, history of glucose
lowering drugs, no diabetic retinopathy in fundus
examination, fasting blood sugar less than 180 mg/dl
and HbA1c les than (7%) immediately before
accommodative tests. Inclusion criteria for control
group were healthy individuals in same age range
without diabetes. Exclusion criteria were evidence of
diabetic retinopathy (proliferative or nonproliftrative)
in diabetes group, previous ocular surgery, systemic
disease, history of anticholinergic drug use for both
groups. Demographic data including age, gender, type
of diabetes (insulin-dependent or non-insulin-
dependent) and duration of disease were recorded.
Detailed ocular examination including best corrected
visual acuity for distance under cycloplegia, movement
including alternate cover test for detection of any
phoria or tropia, biomicroscopic and fundus
examination were performed on both groups. Fasting
blood sugar was measured and in case of being less
than 180 mg/dl, accommodation ability tests were
performed.Accommodation ability tests consisted of
multiple experiments which was performed by single
optometrist and rechecked by an expert
ophthalmologist. The study was double-blinded and
intraobserver and interobserver variability were
controlled by another examiner. These means,
examiners were blinded for both group in which the
subjects belonged and measurements obtained by the
optometrist and ophthalmologist. Each test was
performed two times in individuals by observer and
average of result considered for statistical analysis. All
tests were run binoculary and instruction set was
similar to cases and controls. These accommodative
tests include:
Near Point of Accommodation (NPA):
It was measured by the push-up method. While the
participant wearing his/her best distance correction, a
(20.20-20.40) size target on the ruler moves slowly
toward the nose until the observer reported the first
blur. The distance from ruler was read and expressed as
centimeter. Accommodative Amplitude defined as the
reciprocal of near point of accommodation and
expressed as diopter.
Accommodation Facility (AF):
With proper distance correction, accommodative
target (20.20-20.40 sizes) was viewed at near distance
(40 cm). ±2.00 D lens pairs mounted in a handheld
flipper frame were repeatedly introduced over both
eyes and the time needed to see the target clearly was
measured. Test duration was one minute and expressed
as Cycle (times to see the target clearly) Per Minute
(CPM).
Relative Accommodation (RA):
With proper refractive correction for distance,
accommodative target was viewed. Minus or plus
sphere with (0.25)D interval in power incrementally
replaced until the observer could not see the target
204
Accomodationin Diabetis
clearly. The strongest power which causes blurring was
recorded and expressed as diopter (negative value for
positive relative accommodation and positive value for
negative relative accommodation).
Near Point of Convergence (NPC):
It was measured by the ruler and push-up method. In
this technique (20.20-20.40) target size on ruler was
moved toward to the observer. Nearest point when
patient lose his/her fixation or developed diplopia is
defined as the near point of convergence and expressed
as centimeter.
Statistical analysis:
Statistical analysis was performed using SPSS
Version 16 (SPSS Inc., Chicago, IL). The normality
ofdatadistributionwascheckedwithKolmogorov–
Smirnov test.
The differences in accommodation functions
between groups were tested using student’s T-test, Man
Whitney and repeated measures analysis of variances.
The level of significance was set at P-values<0.05.
Results
Case and control groups included 32 and 28
individuals, respectively. Male to female ratio was 2.3.
Mean age was 35±6 years in the case group and 31±4
in the control group (p=0.000). Mean Fasting Blood
Glucose (FBS) was (170±8) mg/dl in the case and
(85±16) mg/dl in the control group. Mean refractive
error was (0.50±2.17) D in the case and (0.25±2.75) D
in the control group which was not statistically
significant (p=0.1). All subjects had orthophoria. Table
shows various accommodation parameters measured in
population study.
Table1: Measured accommodation parameters in population
study
Mean Diabetic Control P value
NPA(cm) 9.5±2 18.5±4.4 0.000
AA(D) 5.93±1.75 10.95±2.16 0.000
AF(cycle/minute) 3.19±3.04 10.01±5.09 0.000
Positive relative
-3.37±1.19 -2.11±0.99 0.000
accommodation(D)
Negative relative
2.61±0.65 2.61±0.60 0.23
accommodation(D)
NPC(cm) 8.23±1.43 7.13±0.67 0.45
Near Point of Accommodation (NPA), Centimeter (cm),
Amplitude of Accommodation (AA), Diopter (D),
Accommodative Facility (AF), Near Point of Convergence
(NPC)
Mean NPA was (18.5±4.4) cm in the case and
(9.5±2) cm in normal individuals; this difference was
significantly different (p<0.001). In addition, the
difference of mean AA was statistically significant
between groups (+5.93±1.75) D in the case and
(+10.95±2.16) D in the control group) (p<0.001).
Mean AF was (3.19±3.04) CPM in the case and
(10.01±5.09) CPM in the control group; which the
difference was statistically different (p<0.001). Mean
positive RA was (-3.37±1.19) D in the case and
(-2.11±0.99) D in the control group which had a
Patient Saf Qual Improv, Vol. 3, No. 2, Spr 2015
Etezad Razavi et al
significant difference (p<0.001). Mean negative RA
was (+2.61±0.65) D in the case and (+2.61±0.60) D in
control group which had no significant difference
(p=0.235). Mean NPC was (7.13± 0.67) cm in the case
and (8.23±1.43) cm in the control group; however, this
different did not reach statistical significance (p=0.45).
Discussion
Accommodation insufficiency is the premature loss
of accommodative amplitude (1).This problem may
manifest itself by blurring the near visual objects or by
inability to sustain accommodative effort. The onset
may be heralded by the development of asthenopic
symptoms, with ultimate development of the blurred
near vision. Such premature presbyopia may indicate
concurrent or past debilitating disorder such as diabetes
mellitus or it may be induced by medication such as
tranquilizing drugs or the parasympatholitic used in
treating some gastrointestinal disorders. In both cases,
the condition may be reversible, however, permanent
accommodative insufficiency may be associated with
neurologic disorders such as encephalitis or closed
head trauma. These patients require reading addition
for their near vision (1, 2).Diabetes mellitus is a major
cause of blindness in 20-74 years age individuals in
United State (4). Accommodative insufficiency is one
of the problems which is usually neglected in these
patients and may affect their quality of life if not
treated properly. Few previous studies have
investigated the accommodation changes in young
diabetic patients. For example, in a study Duane in
1925 measured NPC and AA in healthy
individuals,which has been considered a reference for
further studies till today (5).In another investigation,
Pawelski and Glien in 1971 compared accommodative
amplitude between white American diabetic and
healthy subjects in young age and measured AA by the
push up technique. They found a decreased AA in
diabetic group (6).Another study by Moss in 1988 on
61 subjects ages ranged 9-16 years in two groups
(diabetic versus normal) showed lower AA in diabetic
References
1-Optic of human In: Clinical optics. Basic and Clinical
Science Course. American Academy of
Ophthalmlogy.2010-2011 page: 115-7.
2- Glasser A, Kaufman PL. The mechanism of
accommodation in primates. Ophthalmology. 199;
106(5):863-872.
3-Braun CI, Benson WE, Remaley NA, Chew EY,
Ferris EL. Accomodative amplitude in the early
treatment diabetic retinopathy study. Retina. 1995;
15(4):275-83.
4- Diabetes mellitus In: Retina and Vitreous. Basic and
Clinical Science Course. American Academy of
Ophthalmology.2010-2011 page 145-155.
5-Duane A. Subnormal accommodation. Arch
Ophthalmology. 1925; 54(4):566-587.
6-Pawelski WJ, Glien H. Studies on accommodation
205
Accomodationin Diabetis
patients (9.9 versus 11.8 D)(7). The present study was
performed on young Iranian diabetic and healthy
subjects. The NPA and NPC measurements are more of
less similar in terms of the technique. Yet, only the
NPA deteriorates in diabetes while the NPC remains
relatively unaffected. We have an explanation for why
this might be the case. Logically it seems like the
diabetic subjects should have seen the targets blurred
for closer distance (distances closer than the NPA) in
the NPC measurements and our subjects report this.
Ethnicity is important parameter that may influence
the results of previous studies (8, 9, and 10). In contrast
to the ETDRS study, due to small sample size, we did
not evaluate the association between gender, type or
duration of diabetes and accommodation parameters
which were measured in ability tests. Similar to other
studies, we found that most accommodation ability
tests including AA were lower in diabetic patients. One
advantage of the current study was quantification of
multiple accommodation parameters in normal and
diabetic patients which was not evaluated in other
studies. Accommodative performance may be
correlated with biochemical parameters measured in the
experiment(i.e. HbA1c levels or FBS). We did not try
to see these relations but it might provide more insights
into why accommodative performance may be
deteriorating in diabetic patients. A considerable
problem of the tests employed is their subjective
component since one has to rely on patient's perception.
Hence, we suggested using objective methods to
measure accommodation.
Conclusion
Defective accommodation may develop in young
diabetic patients. Early diagnosis and rehabilitation
with proper corrective lenses may improve symptoms
and probably improve quality of life in thesepatients.
Acknowledgment
We acknowledge everyone who contributes in
formation of this article.
range in diabetics. Ophthalmologica.1971;
163(4):216-26
7-Moss SE, Klen BE. Accommodative ability to
younger onset diabetes. Arch Ophthalmology. 1987;
105(4):508-12
8- Spafford MM, Lovasik JV. Clinical evaluation of
ocular and visual functions in insulin-dependent
juvenile diabetics. Am J Optom Physiol Opt. 1986
Jul;63(7):505-19.
9- Mäntyjärvi M, Nousiainen I. Refraction and
accommodation in diabetic school children. Acta
Ophthalmol (Copenh). 1988 Jun;66(3):267-71.
10-.Braun Cl,Benson WE,Remaley NA,Chew
EY,Ferris FL.Accommodativamplitudes in the early
treatment diabetic retinopathy study.retina
1995,15(4)275-9.
Patient Saf Qual Improv, Vol. 3, No. 2, Spr 2015